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Landscape of program inputs  Facility readiness assessment using 8 parameters was conducted in Oct 2010 using a structured questionnaire and 75 indicators generated.  KAP performance for maternal and newborn care especially neonatal resuscitation was mapped.  District mapping of the gaps generated and facility wise plan made for realistic program. Based on this implementation included provider mapping,  3- Day skill based training in essential newborn care and resuscitation skills of all district level primary providers conducted (250)  Job-aides and skill lab of key providers (28) in the demo-facilities.  Supportive supervision involving quantitative and qualitative checklists was used to provide on-going hand holding. Involving district authorities at each step was critical to success of the program.  Strengthening of health information systems by improved reporting and feedback mechanism,  Follow up of facility births of birth asphyxia newborns conducted in the community.  Facility readiness assessment using 8 parameters was conducted in Oct 2010 using a structured questionnaire and 75 indicators generated.  KAP performance for maternal and newborn care especially neonatal resuscitation was mapped.  District mapping of the gaps generated and facility wise plan made for realistic program. Based on this implementation included provider mapping,  3- Day skill based training in essential newborn care and resuscitation skills of all district level primary providers conducted (250)  Job-aides and skill lab of key providers (28) in the demo-facilities.  Supportive supervision involving quantitative and qualitative checklists was used to provide on-going hand holding. Involving district authorities at each step was critical to success of the program.  Strengthening of health information systems by improved reporting and feedback mechanism,  Follow up of facility births of birth asphyxia newborns conducted in the community.

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Quality Improvement Quality Improvement (QI) approach is being used to analyse performance of the providers during training; and thereafter using systematic effort to improve the competence for the skill proficiency on neonatal resuscitation for improved outcomes.

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QI areasCriteriaToolsPurposeMeasuredResults Skill acquisition Knows the steps and their sequence to perform the required skill but needs assistance Quality Assurance Checklist (QAC) Performance checklist (PC) QAC is used to document the inputs and process followed during the training Skill rating (Mega-Score) using pre-post checklist During training QAC results Pre-post test results Skill competency Knows the steps and their sequence and can perform the skill Read and Do tools (R&D) Supportive supervision (SS) Health worker with a step by step outline of the procedure for use during the practice phase of lesson. Standard checklist used during supervisory visits regular intervals During mentoring Self – Practice observations SS checklist Skill Proficiency Knows the steps and their sequence and effectively performs the required skill Cross-learning visits Knowledge attitude Practice (KAP) HIMS trends Best Practices are focused Change in behaviour & practice Survival rates During bench- marking exercises Facility Readiness

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Skill Acquisition - QI Quality Assurance Checklist  Been used to assess and adhere to a minimum standard for quality of process during the training.  10 observation questions  Score less than 80, training is repeated. Pre-Post Performance checklist  Pre-post test scores are used to rate the training and provide feed-back to the providers.  Measure changes in both the knowledge and skill acquisition by the health providers as a result of the training.

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Supportive supervision  A structured guide & training methodology for supportive supervision was prepared  An “yes and no “simple checklist” is being used for regular supervision & feedback.  Each skill is only scored, if all the steps is followed for the skill.  The checklist has two copies, one for the health provider being supervised and the other for the one who supervises the activity. By this mean we assured that the provider who was supervised knows the misses and can be motivated to improve his performance.

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Skill Competency QI  Questionnaire and exercise methodology developed to focus on the “preparedness” of the health facilities to deliver newborn care services as per the national guidelines.  The results framework is quantifiable in operational terms rather than health systems framework.  The analysis tool works on 75 broad indicators to generate color- codes to map the status of 8 parameters – Infrastructure, Delivery and Newborn Care services, Human resource, Essential drugs, equipment and supply, Register and client case record, Protocols and guidelines, universal precautions & infection prevention and Provider’s knowledge & competency on core skills.  A computerized SQL based analysis system has been developed to generate score based color-codes.  Implementing a planning exercise based after this exercise is found very useful and allowed us to bench mark the health facilities over a period of time.

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Resuscitation Details District Name Facility Name Number of still borns resuscitated (X) Still borns brought back to life (BV-CU) Number of newborns with asphyxia (AJ) Number of newborns with meconium (AI) Number of newborns who had floppiness (AK) Number resuscitated by stimulation only Number resuscitated by stimulation and suction Number resuscitated by stimulation,suction and bag and mask Number resuscitated by stimulation,suction and bag and mask and oxygen Total number of newborns on whom bag and mask has been used Total number of newborns with asphyxia or meconium or floppiness (AJ+AI+AK) JAMDH 332437511337131427 67 JAMPabia 360810004808 DEO Palajori 718181201527 29 DEOMadhupur 300615342325 18 All sites total 84382125368442918 47 124

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26 Lessons Learned  Newborn care programs have tended to be vertical, and slow to take up, have not considered or contributed to their quality.  It is feasible and beneficial to integrate ENC with Maternal Health programs and improve quality of care and have access to their concomitant resources.  The mother and baby dyad can be assessed and managed together.  The first week, especially the first three days, should be covered as a priority in the most feasible and effective manner at both facility and community levels with links between the two.